Maggie Walsh-Cotton, LMT, CLT, MLD-C
Call for an Appointment 937-478-9038
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Lymphatic Request for New Clients
​This form is required before your first Lymphatic appointment can be made. 
Once submitted, a therapist will contact you to complete the booking process.

Why are you seeking Lymphatic Therapy? 

If this is for post-op procedures, please provide following: 
  • the type of procedure 
  • date of surgery 
  • any complications, issues or concerns.
Physician's Name and Contact Information whom has cleared you to receive Lymphatic Therapy
​​Please answer as specific as you can, generalized answers or an incomplete form will not be accepted, as this will help determine your eligibility to receive Lymphatic work at our facility.
Minor Swelling that comes and goes periodically
Persistent swelling with heat and redness
Inability to walk or move without assistance
Inability to sit or lay down
Cancer, Surgery or Radiation of Lymph Nodes
Cardiac Conditions
Upcoming surgery
Diagnosis of Lipedema
Diagnosis of Lymphedema
None of these
Areas that are leaking or weeping fluid
Areas of acute soreness
Sinus pain or pressure